Medical education is prized in India. The competition to gain entry into government
medical colleges is fierce, while admission to most private medical schools costs
a fortune. It is also well known that there is a marked variability in the standards
and settings of medical education across the country. Nevertheless, training in evaluating
scientific literature and in medical writing is poor across medical schools, often
nonexistent. Even the best medical colleges neither train their undergraduate and
postgraduate students in scientific and medical writing nor do they empower their
faculty to discuss and debate local and relevant issues in medical literature. Despite
publications from the country in some of the best National and International Journals,
the general quality of medical writing from India is poor. The paucity of role models,
the absence of a strong academic environment, minimal publication requirements for
promotions of academics, and a dearth of formal training in medical writing all contribute
to low standards of medical writing in India.
Nevertheless, islands of academic excellence do exists; however, these are often driven
by specific individuals, who seem to create a learning and academic environment around
themselves; they engage with local issues, break out of their disciplinary straight-jackets,
and challenge existing paradigms. On the other hand, medical schools do not emphasize
the importance of the need to study locally relevant issues, document regional conditions,
varied contexts, unusual comorbidity, differing outcomes, the need for distinctive
treatment strategies, and to communicate complex issues. They also do not empower
young physicians, during medical training, to question conventional wisdom and to
view issues from a perspective that is different. The majority of academic publications
from India replicate Western findings and doctrines; these are often produced only
to meet the extremely low standards required for academic promotions in the country.
Attempting to attain mastery in written communication, to think differently, and to
highlight distinct patterns is rare, even in the best medical institutions.
Much blame for the failure to empower young physicians lies with senior faculty, who
preside over impoverished academic environments. They perpetuate cycles of mediocrity
and often destroy bright young careers with their failure to facilitate and promote
growth among younger colleagues. The Indian cultural emphasis on rote learning encourages
parroting of medical trivia rather than stimulating critical thought, thereby stifling
creativity and innovation. It inculcates bad attitudes even among those with reasonable
intellectual and language skills. Even the few who take up the challenge of serious
academic pursuits often fail due to the lack of support from colleagues, mediocrity
of scholastic milieu, low academic standards, minimal requirements for academic advancement,
and the absence of a critical mass of proficient teachers and role models. The lack
of such exemplars in Indian academia mandates the need for more Ekalavyas, who
are able to build ideal role models in their imagination and follow them.
IDEAS AND CONFIRMATION
John Snow, considered the father of epidemiology, is recognized for his contribution
to the identification of the spread of cholera in London. The story of the “death
map” and the “broad street pump” is history. However, these also beg the question
“who was the real John Snow?” Was he the one convinced that cholera spread through
water after he drew the map of the residents of Soho, who were infected with cholera?
Alternatively, did he suspect that cholera was a water-borne disease even before the
Broad Street episode? Evidence suggests the latter, arguing that many ideas are gained
through experience and reasoning;[2
3] however, they require formal confirmation using appropriate study designs and analyses.
While disciplinary straight-jackets often stifle innovative thought, Indian academia
faces a more daunting challenge. Despite close to seventy years of independence from
the British Raj, our minds continue to be colonized by the West. Western and international
frameworks dominate the academic discourse to such an extent that unexpected findings,
which do not neatly fit into accepted models, are discounted or brushed under the
carpet. Alternative hypotheses and approaches are rare, as much effort is devoted
to replicating findings in Western literature and slavishly submitting to supposed
universal truths, despite evidence of major differences in local reality. Many studies
are also limited by diffidence in interpretation of new findings and the timidity
of authors to pursue alternative hypotheses based on the evidence generated.
Academic promiscuity is another ill that plagues many individuals involved in research
in India. Attempting to be jack-of-all-trades results in limited mastery of the many
areas studied. The failure to examine different aspects of a particular issue in detail
makes for poor understanding of the complexity of problem involved. The focus on the
number of papers produced results in thinly sliced salami publications and superficial
studies, rather than rigorous and in-depth work that could result in substantial progress.
ENVIRONMENT AND PRACTICE
The postdoctoral working environment generally seems to determine the future trajectory
of academic and scientific careers. Settling into departments with limited academic
output often puts the seal on many promising careers. The sole aim of meeting requirements
of universities and the Medical Council of India with regard to publications required
for promotions, which sets the bar extremely low, is guaranteed to breed mediocrity.
The absence of local mentors often demands creation of a virtual college of physicians
and scientists, who are serious about their academic life and work. Attending workshops,
utilizing training fellowships, and study and sabbatical leave opportunities can help
kick-start the quest for excellence and allow one to escape the cycle of mediocrity.
Needless to say, such initiatives require a tremendous amount of hard work and discipline,
far beyond what many faculty members in Indian institutions are usually willing to
The adage that “practice makes perfect” cannot be over-emphasized. Many opportunities
are available in one's career to exercise skills in academic writing; these include
writing of case reports, case series, project proposals, dissertations, theses, and
grant applications. Use of such opportunities allows young faculty members to practice
their writing skills. The numerous publications available in the age of the Internet
also mean that there are journals waiting to publish papers, even those with limited
scientific merit, allowing for practice in writing and communicating ideas. The ability
to identify suitable journals and match them with manuscripts, with regard to the
quality of the study, reader's interest, and topicality, will allow publication of
even the most inane research and ideas; this will provide practice in improving written
language and writing skills.
Studying impact factors of journals, their focus (e.g. general scientific/general
medical journal/specialty publications), and the target audience (e.g. international/national/regional)
will help place studies appropriately on their eventual publication platforms. Compiling
lists of potential journals and going down such a list is useful. No data obtained,
however limited the methodology used or humble its message should be filed into drawers
without publication. A listing of the limitations of the study in the manuscript will
allow for improvement in future designs, analysis, and interpretation. On the other
hand, the failure to send material for publication would not allow for many learning
experiences and growth. Making decisions on sending a manuscript to different sections
within journals (for example, full article, short reports, correspondence, etc.) also
helps. One has to believe that there are journals waiting to publish the study, and
the task is often of identifying the right publication.
SUGGESTIONS FOR WRITING
Reviewing relevant literature, identifying a problem, stating a hypothesis, understanding
study design, adopting robust and appropriate methodology to address the research
question (s) being asked, meticulously carrying out the study, interpreting data obtained,
presenting evidence in text, tables, and graphs, and developing a logical discussion
and conclusion are crucial parts of the process of preparing a manuscript. Studying
the journal format, style guidelines, instructions, and checklists for authors is
a good start [Box 1]. Examining similar papers for templates is also useful. Reviewing
standard guidelines to include the necessary details for standard study design, analysis,
and presentation (e.g. CONSORT for randomized trials, STROBE for observational
studies, STREGA for genetic association studies, etc.,) is helpful.
Basic suggestion for improving writing skills
Writing an outline for a manuscript helps provide structure to it. Identifying the
available material under various heads and sub-heads helps focus the writing. Recognizing
ideas and themes for specific paragraphs is a useful strategy. While a perfect first
paragraph will take time to develop, completing a rough first draft of the whole paper
will increase confidence and allow for a sense of satisfaction about progress made.
Revising and editing one's written work multiple times is often necessary to improve
the quality of the finished product, and requires patience and attention to detail.
Breaking one's mental set by working on multiple papers or projects simultaneously
allows for a change of content, context, and frame of mind, and often results in a
fresh and different approach to the topic and to its writing.
The use of short sentences with simple structures is cardinal. Checking the presentation
for logical flow of ideas is necessary. The use of active voice improves presentations.
Spell checks are mandatory. Customizing word processing programs, by changing default
settings, for an exhaustive grammar check is useful for beginners; rating the article
using readability statistics, now available with many word processors, and attempting
to improve the scores are useful. Since many journals, particularly those of good
standards, have in-house facilities to improve language, the focus of the writing
should be on content and technical detail. High costs of printing mandate brevity
and precision in one's writing.
While many professional organizations help with writing, editing, and publication,
outsourcing medical writing to these will hinder personal and academic growth. Choosing
a local mentor, to guide one through the process, will allow for step-by-step corrections
Understanding issues related to plagiarism, and avoiding it by learning to cite previous
work correctly, is critical to progress as a writer and author. The temptation to
plagiarize, surely and certainly, leads authors to mediocrity as it ensures the failure
to understand basic principles of thinking and writing, and prevents personal and
While medicine and science may be complex, most people assume that such complexity
is inevitable and difficult to explain. However, such difficulty need not (and should
not) lead to ambiguity or obscurity of expression; clarity of thought and lucidity
of writing can illuminate scientific issues without erroneously oversimplifying them.
Nevertheless, the writer must fully understand the readers’ needs to clearly and effectively
communicate what they wish to. Readers, including journal editors and reviewers,
do not simply read; they also analyze the content and make interpretations. Consequently,
issues related to context and reader expectations are crucial for effective communication.
Information is more easily interpreted when readers find it in places they expect.
Strictly adhering to section heads (e.g. introduction, methods, results, discussion,
etc.,) and to sub-heads makes for less confusion and much less effort to understand
on the part of readers. Placing context and known information first before presenting
new information and innovative arguments is useful. As we read from left to right,
structures of tables should present familiar information on the left and newer evidence
on the right. The first and last sentences in each paragraph should generally connect
to the previous and next paragraphs, respectively, allowing for continuity of thought.
Readers should neither have to work hard to decipher the content of paragraphs nor
should they be made to guess what the author may mean. Convoluted sentences are best
avoided. Simple sentences, with short separation between subject and verb, make for
easy understanding. Arranging emphatic information at the end of sentences, as
readers commonly lay more emphasis to material placed there, allow writers to communicate
new or important information. Alternatively, a whole list can be placed in such “stress
positions,” if they are announced at the beginning of the sentence. In addition, breaking
the sentence using colons and semi-colons can create secondary stress positions. These
useful rhetorical principles suggest the need for the following general rules: (i)
Grammatical subjects should be followed as soon as possible by their verbs, (ii) every
unit of discourse (for example, a sentence/paragraph) should make a single point,
and (iii) information, which needs to be emphasized, should appear at the stress position,
usually closing the argument.
Although proverbial wisdom states “save the best for last” to argue for emphasis,
the proverbial contradiction states “ first things first” to contend that new topics
need to be clearly introduced. Introductions and first sentences should provide
perspective, linkage, and context; old information provides context, whereas new information
emphasizes the author's message. Clearly stating the hypothesis under question and
then providing evidence for or against is required. Attention to detail is critical
The fact that readers interpret what they read suggests that authors can increase
the odds of effectively communicating their intended meaning to a majority of their
readers. Content of thought process and expression of thought are intertwined.
Awareness of writing rules will improve the structure of the prose and the quality
of the scientific argument. While there are no absolute rules for good scientific
writing, writers who make consistent choices and improve sentence construction and
structure, improve their communication over time.
Rejection is a fact of life for every academic. Managing emotional reactions to rejects
is crucial for successful academic careers. Understanding and respecting the process
of peer review and placing oneself in the reviewers’ and editors’ shoes and re-examining
issues related to merit, journal focus, audience, reader's interest, and topicality
will allow authors to better match their articles to possible platforms for publication.
While we may be critical (and resentful) of the reasons for rejection, we have to
accept that peer review is the best system we currently have for research and publication.
The challenge, in handling rejections, is to choose a wise path between modification
and completely rewriting of papers. Incorporating reviewers’ comments is mandatory.
Including modifiable suggestions, while acknowledging limitations for changes that
are not possible, is useful. Even the most mundane criticisms may deserve incorporation
as it suggests that the text was unclear, making it difficult for the average reader
to fully understood the issues. Quickly moving on to submission to other journals
suggests an understanding of the peer review and publication process and of emotional
Academic careers, with their emphasis on scholarship and research, mandate innovations
in thought, effective communication of ideas, and being engaged with study and research
in the field one has chosen. India needs role models, who practice, persevere, and
attempt to move toward perfection, thus, breaking the cycle of mediocrity. The key
to success is focusing and enjoying the process of questioning the status quo, generating
new ideas, testing different hypotheses, collecting and analyzing data and communicating
results rather than on counting the number of papers published; these will allow for
personal and academic growth and enable one to move from being a student to a leader
in the field.
Scientific and medical writing is both an art and a science, like the practice of
medicine. India needs many more clinicians, teachers, researchers, and academics who
can present their ideas to larger audiences and mentor their younger colleagues in
critical thought and in clarity of communication. Reflection and writing should not
only be lifestyle choices for academics, but also part of the work ethic of institutions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.